Fire Alarm System Inspection Documentation Deficiency
Penalty
Summary
The facility failed to maintain the fire alarm system as required, specifically missing documentation for one of the two semiannual visual inspections. During a documentation review on December 3, 2024, it was discovered that the facility did not have records of a semiannual visual inspection of the fire alarm system. This deficiency was confirmed in an interview with the Facility Administrator and Maintenance Director, who acknowledged the absence of the necessary documentation for the inspection.
Plan Of Correction
Unable to correct past deficient practice. The Administrator will educate the Maintenance Director on requirements of K0325. The Maintenance Director will complete and document a visual inspection of the fire alarm system. Maintenance Director will have TELS tracking system (electronic maintenance ticketing and preventative maintenance program) updated to include semiannual visual inspections of the fire alarm system added to the PM (Preventative Maintenance) tasks. The Maintenance Director will complete and document a visual inspection of the fire alarm system semiannually and maintain record in the Life Safety Survey Preparedness Manual. Reports will be shared in the following safety committee for any additional review and or recommendations, ongoing.